Severe Coronary Narrowing Research Articles

Non-ST-elevation infarction, the stepchild of interventional myocardial salvage: experience of a single institute

The diagnosis of acute myocardial infarction is based on ECG abnormalities besides to chest pain and dyspnea. It is caused by myocardial hypoperfusion, in most patients due to severe coronary artery narrowing or occlusion, but it can also occur without visible coronary artery changes. The non-ST-elevation form (NSTEMI) is usually associated with less complaints compared to the ST-elevation form (STEMI), the ECG changes are not so typical, so its recognition is more difficult in the early stage. Possibility of myocardial cell damage reduction is the restoration of perfusion with coronary intervention. To investigate how much time elapses in acute NSTEMI from the onset of the complaint to the opening of the coronary vasodilator balloon. From 3733 acute coronary interventions performed in NSTEMI between 01. 01. 2016 and 12. 31. 2020, in 1376 patients who underwent percutaneous intervention for the first time, the onset of the complaints, the date of the first medical contact and opening of the balloon, as well as the 30-day or 1-year mortality were known. The median values of the time differences and the mortality data were compared with the similar data of 1718 STEMI patients of this period. The median times were given in hours:minutes, incidence in percent, a two-sample t-test was calculated for the comparison of mortality data. In NSTEMI, the median time between the first medical contact (5:35 vs. 2:05 h:min) and PTCA balloon opening (18:12 vs. 4:05 h:min) was longer compared to the onset of the complaint as in STEMI. Within 2 hours, 21.3% of NSTEMI patients reached the first medical contact and 1.2% had the PTCA balloon opened, in STEMI this ratios were 48.7% and 11.7%. Within 4 hours, these were in NSTEMI 36.3% and 6.1%, in STEMI 64.1% and 46.8%. The 30-day mortality rate in NSTEMI was lower than in STEMI (5.9% vs. 7.9%, p = 0.03), the 1-year rate was higher (16.1% vs. 12.5%, p = 0.004). In 554 primarily admitted patients who met the study criteria, the median P-B time intervals were shorter (10:55 h:min), the mortality data showed a mild but statistically insignificant difference (5.6% at 30 days, 13.9% at 1 year). Based on the 1-year mortality data, NSTEMI cannot be considered less harmful compared to STEMI. After the onset of hypoperfusion, myocardium necrosis proportional to the elapsed time increases the likelihood of subsequent heart failure. For this reason, it seems advisable for patients to reach the intervention center earlier than at present due to the invasive diagnostic and therapeutic options. Orv Hetil. 2023; 164(47): 1865-1870.

Characteristics, circumstances and pathology of sudden or unnatural deaths of cases with evidence of pathological hoarding

The study aimed to determine the characteristics and circumstances of cases sudden or unnatural death (n = 61) with evidence of pathological hoarding, their major organ pathology and toxicology. The mean age was 65·8 yrs (a mean of 16.1 years of potential life lost), 62·3% were male, and 28·2% were obese. 95·1% lived alone, and 96·7% died in their residence, with no medical intervention. In all cases severe squalor and extensive hoarding were noted. The direct cause of death was attributed to disease in 75·4%, heart disease being a significant factor in 52·5%. Accidents causing death directly related to hoarding occurred in two cases. Autopsy revealed extensive pathology: severe coronary artery narrowing (42·4%), myocardial replacement fibrosis (44·1%), emphysema (39·0%), nephrosclerosis (46·6%). Signs of hypothermia were present in 14·8%, and diabetes was diagnosed in 21·3%. The most commonly detected substance was alcohol (32·1%). Medications for heart disease (5·4%) or diabetes (7·1%) were rare. The overall clinical picture was of an isolated group, with a heavy burden of physical disease and, in all probability, a high level of psychiatric disorders, who died alone in their homes.

Relation of Severe Coronary Artery Narrowing to Insulin or Thiazolidinedione Use in Patients With Type 2 Diabetes Mellitus (from the Bypass Angioplasty Revascularization Investigation 2 Diabetes Study)

Patients with diabetes continue to die of coronary artery disease (CAD) at rates 2 to 4 times higher than patients without diabetes, despite advances in treatment of cardiovascular disease. The role of glycemic control therapies, independent of their glucose-lowering effects, on cardiovascular disease is a recurring question. We examined the association of glycemic control therapies with extent of CAD as measured by coronary angiogram obtained at baseline in 1,803 subjects in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial who had type 2 diabetes mellitus, documented moderate to severe CAD, and no previous cardiac revascularization procedures. The association between glycemic control therapy use recorded at baseline and percent coronary artery stenosis and myocardial jeopardy index was analyzed by multiple regression models. Insulin use at study entry was associated with 23% fewer highly stenotic lesions (> or =70%) (p <0.001) and a significantly lower myocardial jeopardy index compared with subjects not on insulin, despite a worse cardiac risk factor profile, more unstable angina, and increased inflammatory markers in insulin users. Subjects taking thiazolidinediones (TZDs) for > or =6 months had 17% fewer highly stenotic lesions (p = 0.02) and significantly lower C-reactive protein, fibrinogen, and plasminogen activator inhibitor-1 levels compared with those not taking TZDs. In conclusion, this cross-sectional study of patients with type 2 diabetes mellitus and CAD showed that treatment with insulin or TZDs was associated with fewer highly stenotic lesions, independent of disease duration, glycemic control, and other risk factors.

Cardiac Hemodynamic and Coronary Angiographic Characteristics of Patients Being Evaluated for Liver Transplantation

With improved survival after liver transplantation (LT), the referral of older candidates has increased. The increasing demand for, and the decreased supply of, liver donors makes careful preoperative cardiac risk assessment imperative. There is a paucity of information regarding the cardiac characteristics of patients being referred for LT in the current era. This study aimed to describe the cardiac hemodynamic and coronary angiographic characteristics of a cohort of patients with end-stage liver disease without known coronary artery disease (CAD) being evaluated for LT. One hundred sixty-one consecutive patients aged>or=45 years with end-stage liver disease who were referred for right- and left-sided cardiac catheterization as part of a liver transplant evaluation were identified. There was a high prevalence of atherosclerotic risk factors; half had hypertension or diabetes, and more than half had >or=2 coronary risk factors other than age. There was a high prevalence of CAD, with 26% having unknown moderate to severe coronary narrowing. Patients with moderate to severe CAD were older, were more likely to be men, and were more likely to have hypertension or diabetes mellitus. Right- and left-sided filling pressures were elevated, suggesting abnormalities in left ventricular diastolic compliance. In conclusion, this study showed a high prevalence of coronary risk factors and unknown moderate to severe CAD in patients with end-stage liver disease being referred for LT.

The Influence of Obstructive Sleep Apnea on FFR Measurements for Coronary Lesion Assessment

Fractional flow reserve (FFR) determinations have been demonstrated to be largely independent of changes in systemic hemodynamic changes. Herein, we describe a case of obstructive sleep apnea cyclically altering FFR measurements from normal to abnormal in a patient with an intermediately severe coronary narrowing following treatment for an acute coronary syndrome. To eliminate uncertainty, FFR measurements should be made if possible during suspended respiration.

One-dimensional ultrasonic strain and strain rate imaging: a new approach to the quantitation of regional myocardial function in patients with aortic stenosis

Abnormalities in regional left ventricular (LV) function in aortic stenosis (AS) have yet to be appropriately characterized. One-dimensional strain (epsilon) and strain rate imaging (SRI), new ultrasound (US) indices for quantifying regional wall deformation, might allow this. The aims of this study were 1. to define regional radial and longitudinal epsilon /SR in AS; 2. to establish if they are related to the severity of the disease; and 3. to determine if regional deformation is further altered by coexistent coronary artery disease (CAD). A total of 40 patients were studied: Group I with isolated AS (10 women, 10 men; mean age 66 years) and group II with AS and concomitant CAD (CAD/AS) (13 women, 7 men, mean age 68 years). Data were compared to 20 age-matched healthy people (N). Regional systolic maximal velocity/SR and end-systolic and maximal epsilon were measured. The maximal systolic velocity/SR in AS and CAD/AS patients were significantly reduced compared to N. The two patient groups could be further differentiated by end-systolic and maximal epsilon, which demonstrated a further reduction in both epsilon indices in CAD/AS (i.e., maximal radial epsilon 29.3%, AS; 23.7%, CAD/AS; 40.4%, N; AS and CAD/AS vs. N, AS vs. CAD/AS, p < 0.05). Indices of radial and longitudinal deformation correlated both with aortic valve area (AVA) and stroke volume (SV) (i.e., radial maximal epsilon and AVA, r = 0.77, p < 0.05). A significant correlation was also found between epsilon indices and the severity of left anterior descending (LAD) or circumflex artery (CX) coronary artery. Regional myocardial deformation in AS is abnormal. In the absence of CAD, the degree of abnormality correlates with aortic valve area (AVA). The severity of the disease was best expressed by changes in regional epsilon. In CAD/AS patients, there was a significant further reduction in end-systolic and maximal epsilon. These changes correlated with the severity of coronary narrowing in the subtending vessel.

Prognostic value of coronary blood flow velocity and myocardial perfusion in intermediate coronary narrowings and multivessel disease

ObjectivesThis study aimed to investigate the roles of intracoronary derived coronary flow velocity reserve (CFVR) and myocardial perfusion scintigraphy (single photon emission computed tomography, or SPECT) for management of an intermediate lesion in patients with multivessel coronary artery disease. BackgroundEvaluation of the functional significance of intermediate coronary narrowings (40% to 70% diameter stenosis) is important for clinical decision making and risk stratification. MethodsIn a prospective, multicenter study, SPECT was performed in 191 patients with stable angina and multivessel disease and scheduled for angioplasty (percutaneous transluminal coronary angioplasty, or PTCA) of a severe coronary narrowing. Coronary flow velocity reserve was determined selectively distal to an intermediate lesion in another artery using a Doppler guidewire. Percutaneous transluminal coronary angioplasty of the intermediate lesion was deferred when SPECT was negative or CFVR ≥2.0. Patients were followed for one year to document major cardiac events (death, infarction, revascularization), related to the intermediate lesion. ResultsReversible perfusion defects were documented in the area of the intermediate lesion in 30 (16%) patients; CFVR was positive in 46 (24%) patients. Percutaneous transluminal coronary angioplasty of the intermediate lesion was deferred in 182 patients. During follow-up, 19 events occurred (3 myocardial infarctions, 16 revascularizations). Coronary flow velocity reserve was a more accurate predictor of cardiac events than was SPECT; relative risk: CFVR 3.9 (1.7 to 9.1), p < 0.05; SPECT 0.5 (0.1 to 3.2), p = NS. Multivariate analysis revealed CFVR as the only significant predictor for cardiac events. ConclusionsDeferral of PTCA of intermediate lesions in multivessel disease is safe when CFVR ≥2.0 (event rate 6%). This selective evaluation of coronary lesion severity during cardiac catheterization allows a more accurate risk stratification than does SPECT, which is important for clinical decision making in this patient cohort.

Relation of thallium uptake to morphologic features of chronic ischemic heart disease: evidence for myocardial remodeling in noninfarcted myocardium

OBJECTIVESThe aim of this study was to investigate the disparity between the extent of myocardial injury as assessed by thallium and the severity of left ventricular (LV) dysfunction in chronic ischemic heart disease.BACKGROUNDAlthough it is believed that thallium differentiates between viable and nonviable myocardium, in some patients with chronic ischemic heart disease, viable regions by thallium may fail to improve function after revascularization.METHODSThirteen transplant candidates with chronic ischemic heart disease (LV ejection fraction = 14 ± 6% at rest) were studied prospectively with stress-redistribution-reinjection thallium single-photon emission computed tomography. We examined pretransplantation quantitative thallium uptake and post-transplantation extent and the histological distribution of collagen replacement in infarcted and noninfarcted myocardium and in 13 age-matched control hearts.RESULTSThe volume fraction of collagen varied inversely with wall thickness (r = −0.70, p < 0.001) and was higher in irreversible (30.9 ± 15.8%) compared with reversible (20.2 ± 12.6%, p < 0.001) or normal thallium segments (15.0 ± 8.7%, p < 0.001). The irreversible thallium segments had lower wall thickness and more severe coronary artery narrowing (9.7 ± 2.8 mm and 95 ± 8%) compared with reversible (11.7 ± 2.7 mm and 87 ± 13%, p < 0.001) and normal thallium segments (12.8 ± 2.6 mm and 80 ± 14%, p < 0.001). Mean volume fraction of collagen was significantly lower in noninfarcted than it was in infarcted segments (13 ± 6% vs. 36 ± 13%, p < 0.001) but exceeded that in the control hearts (4 ± 2%, p < 0.001). Noninfarcted segments had predominantly interstitial fibrosis with either microscopic or patchy areas of replacement fibrosis.CONCLUSIONSIn chronic ischemic heart disease with severe LV dysfunction, patterns of normal, reversible and irreversible thallium uptake correlated with the magnitude of collagen replacement, segmental wall thickness and severity of coronary artery narrowing. The finding of scattered areas of replacement fibrosis in noninfarcted myocardium may explain the observed disparity between LV contractile dysfunction and the extent of myocardial injury assessed by thallium.

Impaired exercise-related myocardial uptake of technetium-99m-tetrofosmin in relation to coronary narrowing and diabetic state: assessment with quantitative single photon emission computed tomography.

Despite the diagnostic efficacy of stress myocardial perfusion imaging, the correlation between the actual perfusion tracer activity and diseased state of a coronary artery has not been studied in detail. We estimated exercise-related perfusion augmentation in relation to disease states of a coronary artery in diabetic and non-diabetic patients by a newly developed quantitative technetium (Tc)-99m-tetrofosmin myocardial imaging technique. Tc-99m-tetrofosmin tomographic imaging with an exercise-rest protocol was performed in 26 stable coronary patients and in 8 age-matched controls. Percent increase (%IR) in myocardial count during symptom-limited submaximal exercise-stress was calculated in 16 non-infarcted polar map segments and in each coronary territory by a subtraction technique with corrections for physical decay and injected tracer doses, and the results were compared with those of angiographically quantified coronary diameter stenosis (%DS). Percent IR and peak heart rate during exercise showed a positive linear correlation both in coronary territories with significant stenosis (%DS > or = 75%) and in control or nonstenotic (%DS < 75%) territories. The regression line in stenotic regions was, however. significantly (p < 0.01) shifted downward compared to that in non-stenotic regions. Percent IR in stenotic regions showed a significant inverse correlation with %DS. Coronary stenosis of 75% or more was identified by a %IR cutoff value of 40% with 77% sensitivity, 70% specificity, and an accuracy of 72%. In coronary territories with a %DS of less than 75%, %IR in diabetic patients was significantly lower (46+/-15%) than that in nondiabetic patients (61+/-25%). Thus, blunted exercise-related augmentation of myocardial uptake of Tc-99m-tetrofosmin correlates with the severity of coronary narrowing and diabetic state.

Relation of C-reactive protein to extent and severity of coronary narrowing in patients with stable angina pectoris or abnormal exercise tests

Recent studies have implicated inflammation in the pathogenesis of coronary artery disease and of acute coronary syndromes.1‐3 Systemic markers of inflammation such as C-reactive protein (CRP) are elevated in patients with coronary atherosclerosis, 4 and increase significantly in patients with unstable angina or acute myocardial infarction.5 CRP levels are also powerful predictors of cardiac complications and death in patients with unstable coronary syndromes5 as well as in healthy men and women without a prior cardiac history.6,7 A potential explanation for the high event rate in patients with elevated CRP levels is that a high CRP level is a marker for more severe and extensive coronary artery disease. This study was designed to determine whether CRP correlates with the extent and severity of coronary atherosclerosis as assessed by coronary angiography. ••• This was a prospective trial. Outpatients with stable angina or an abnormal stress test who were referred for diagnostic cardiac catheterization with coronary angiography were screened. Patients with any preexisting condition that may cause CRP elevation were excluded. This included patients with known inflammatory, infectious, or neoplastic diseases, and patients with a history of myocardial infarction or unstable angina or any percutaneous interventional or surgical procedure within 2 weeks. Patients taking corticosteroids, or nonsteroidal anti-inflammatory or immunosuppressive drugs were also excluded, as were patients with a prior history of coronary artery bypass graft surgery. Cardiac catheterization and angiography were performed in the standard fashion. Each coronary angiogram was read by 2 interventional cardiologists who were blinded to CRP results and agreement was reached by consensus. Stenosis severity was determined using calipers. To assess the extent of atherosclerotic involvement, a coronary atherosclerosis score was designed using the following model. The coronary artery tree was divided into 9 segments: the left main coronary artery, the proximal, mid-, and distal left anterior descending artery (the major diagonal branch was considered part of the mid‐left anterior descending artery), the proximal circumflex artery including the first obtuse marginal branch, the circumflex artery distal to the first marginal branch, the proximal and mid‐right coronary artery, and the posterior descending artery. Each of these segments was scored from 0 to 3 depending on the most severe diameter stenosis according to the following system: 0 5 normal, 1 5 stenosis between 1% and 49%, 2 5 stenosis between 50% and 99%, and 3 5 total occlusion. In the case of total occlusion, each of the segments distal to the occlusion was arbitrarily given a score of 1. A coronary atherosclerosis score was generated as the sum of the scores in all segments. In addition, the number of vessels with coronary artery disease in each patient was calculated as the number of vessels with a stenosis $50%. CRP was measured immediately after insertion of

Decreased baroreflex sensitivity in patients with stable coronary artery disease is correlated with the severity of coronary narrowing

Although studies have shown that arterial baroreflex sensitivity (BRS) is decreased in patients with acute myocardial infarction, BRS changes in patients with stable coronary artery disease (CAD) have not been studied extensively. We assessed BRS by the phenylephrine method in 55 normotensive and nondiabetic patients with chronic effort angina, old myocardial infarction, or both. The control group consisted of 24 age-matched patients without coronary lesions. To identify factors that determine BRS in stable CAD, we performed multivariate analysis using age, sex, left ventricular ejection fraction, pulmonary artery wedge pressure, resting systolic blood pressure, resting heart rate, the number of stenotic coronary arteries, history of myocardial infarction, and the presence or absence of angina pectoris as variables. BRS was significantly lower in patients with CAD than in control subjects (5.9 ± 2.9 vs 6.9 ± 2.4 ms/mm Hg, p < 0.05). In patients with CAD, BRS was inversely correlated with age, the resting heart rate, and the number of stenotic coronary vessels (p < 0.001, p < 0.005, and p < 0.005, respectively), but was independent of other clinical parameters, including the history of myocardial infarction. In control subjects, BRS was significantly correlated only with age. These results indicate that BRS is decreased in patients with stable CAD, and this decrease is correlated with the extent and severity of coronary narrowing.

Dipyridamole stress echocardiography in patients with severe left main coronary artery narrowing

From a population of 2,698 patients (579 evaluated early after an uncomplicated acute myocardial infarction) who underwent dipyridamole echocardiography testing (DET) and subsequent coronary angiography, left main (LM) stenosis ⩾50% was present in 73 (61 men and 12 women, mean age 62 ± 8 years). These 73 patients were compared with a control group comprising 100 consecutive coronary patients without LM disease/ Both groups were similar regarding mean age, sex, incidence of previous myocardial infarction, left ventricular function at rest, and severity of coronary artery disease by the number of diseased vessels excluding the LM. The proportion of patients receiving antianginal therapy during DET was higher in the LM than in the non-LM group (32 vs 14%; p <0.01). No major complication (severe hypotension, sustained arrhythmia, myocardial infarction or death) occurred during DET. Of 73 patients with LM disease, 68 had positive DET (sensitivity 93%), dipyridamole time was 7.1 ± 3.8 minutes, and the rest-peak stress variation in dipyridamole wall motion score index (1 = normal to 4 = dyskinesia, in an 11-segment model) was 0.37 ± 0.23; 14 patients (19%) were resistant to aminophylline and needed nitrates to resolve ischemia. In the non-LM group, DET was positive in 72% (p <0.001 vs LM), with a longer dipyridamole time (9.6 ± 5.2 minutes; p <0.001 vs LM), lower rest-peak stress wall motion score index variation (0.29 ± 0.25; p <0.05 vs LM), and less frequent antidote resistance (1%; p <0.001 vs LM). In the LM group, severity of LM stenosis, and the extent of associated disease did not influence the results of the test, whereas in the non-LM group, dipyridamole time, rest-peak stress variation of wall motion score index, and DET positivity increased with the number of narrowed arteries. DIET is feasible, safe and accurate in patients with LM disease/ Although no pathognomonic response for LM disease could be recognized, the DET positivity pat]tern in the time and space domain was characterized by a shorter dipyridamole time, larger extent and severity of the induced dyssynergy, and more frequent antidote resistance than in patients without LM disease.

Intravenous recombinant tissue-type plasminogen activator in patients with unstable angina pectoris. Results of a placebo-controlled, randomized trial.

Because thrombus formation may contribute to coronary obstruction in patients with unstable angina pectoris, we performed a pilot investigation to determine whether thrombolytic therapy can relieve coronary narrowing in this acute ischemic syndrome. Sixty-seven patients with rest angina and angiographic evidence of coronary stenosis were randomly assigned to receive either low-dose intravenous recombinant tissue-type plasminogen activator (rt-PA) (0.75 mg/kg over 1 hour), high-dose intravenous rt-PA (0.75 mg/kg over 1 hour; total dose, 100 mg over 6 hours), or intravenous placebo followed by repeat coronary angiography at 24-48 hours to assess change in the severity of coronary narrowing. Each patient also received oral aspirin and intravenous heparin. Mean values of coronary stenosis severity (percent of diameter reduction) declined to a similar extent in each group: placebo, 75 +/- 14% to 72 +/- 14% (p = 0.07); low-dose rt-PA, 75 +/- 16% to 71 +/- 18% (p = 0.03), and high-dose rt-PA, 82 +/- 11% to 77 +/- 17% (p = 0.18), with only the low-dose rt-PA group achieving statistical significance. Resolution of intracoronary filling defects, increase in antegrade flow grade, or both also occurred equally among the three groups. There was considerable variation in individual patient response. Between 29% and 50% of patients within each group demonstrated a decrease in stenosis severity, whereas 50% to 57% noted either improvement in antegrade flow or resolution of intracoronary thrombus. There was no difference in incidence of major bleeding events among the three groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative analysis of amounts of coronary arterial narrowing in cocaine addicts

From January 1979 to February 1989, 22 cocaine addicts were studied at necropsy. The 22 patients were divided into 2 groups: death associated with increased cocaine levels at necropsy (13 patients, aged 23 to 45 years [mean 32], and mean total blood cocaine level, 0.36 mg/dl) and noncocaine-related death (9 patients, aged 15 to 50 years [mean 32]). Of the 22 patients, 17 were men and 5 were women; 19 were black and 3 were white. Gross examination in the 22 patients disclosed that 8 patients (36%) had 1 or more of the 4 major (left main, left anterior descending, left circumflex, and right) coronary arteries narrowed at some point >75% in cross-sectional area by atherosclerotic plaque. In 17 cases, the 4 major epicardial coronary arteries were divided into 805 five-mm long segments and a histologic section was prepared from each segment: of the 12 patients with a cocaine-related death, 41 (8%) of 544 five-mm coronary segments were narrowed 76 to 100% and 106 segments (19%) were narrowed 51 to 75% in cross-sectional area by plaque. Of the 5 cocaine addicts who did not die from cocaine overdose, 8 (3%) of 261 five-mm coronary segments were narrowed 76 to 100% and 19 segments (7%) were narrowed 51 to 75% in cross-sectional area by plaque. The frequency of coronary artery disease was greater in patients dying with cocaine in their blood at necropsy compared to those whose death was not cocaine related. Also the frequency of severe coronary arterial narrowing is considerably greater than expected for the entire group of patients whose mean age was only 32 years. Thus, either of 2 possibilities, alone or in combination, may explain our findings: coronary atherosclerosis is accelerated by cocaine addiction for reasons as yet undetermined, or cocaine provides a fatal stress in patients with premature coronary atherosclerosis from other causes.

Acquired ventricular septal defect during acute myocardial infarction: Analysis of 38 unoperated necropsy patients and comparison with 50 unoperated necropsy patients without rupture

Thirty-eight patients (24 men and 14 women) with an acquired ventricular septal defect during acute myocardial infarction (AMI) (rupture group) were studied and their clinical and necropsy findings were compared with 50 patients who died during their first AMI without rupture (nonrupture group). The frequency of systemic hypertension (54 vs 52%), angina pectoris (28 vs 22%) and congestive heart failure (5 vs 0%) before the fatal AMI was similar for both rupture and nonrupture groups. Mean heart weights for men (498 vs 526 g) and women (397 vs 432 g) with and without septal rupture also were insignificantly different. Whereas previous studies of fatal AMI cases have shown that 50% of cases of fatal AMI without rupture have left ventricular scars, only 4 (10%) of the rupture cases had a left ventricular scar before the infarct that ruptured. The rupture group had a significantly more frequent (p <0.01) posterior location of the infarcts (74 vs 40%) and, therefore, a higher frequency of associated right ventricular infarcts 50 vs 18%). The number of 3 major (right, left anterior descending and left circumflex) epicardial coronary arteries narrowed at some point >75% it cross-sectional area of atherosclerotic plaque was the same in both groups. The percent of these 3 arteries totally occluded or nearly so (>95% in cross-sectional area) by plaque was significantly less (p <0.001) in the rupture group compared with the nonrupture group (9 of 99 arteries [9%] vs 38 of 144 arteries [26%]). Analysis of each 5-mm long segment of these arteries in each group disclosed that the rupture group had significantly less narrowing than the nonrupture group. Of the 825 five-mm segments of artery examined in the rupture group (18 patients), only 101 (13%) were nar rowed >75% in cross-sectional area by plaque; in contrast, of the 1,848 five-mm segments in the nonrupture group (38 patients), 508 (28%) were narrowed to this degree by plaque (p <0.01). Thus rupture of the ventricular septum primarily is a complication of the first AMI. It is associated with less severe coronary arterial narrowing than observed in fatal AMI without rupture, and it is a more frequent complication of posterior (inferior) than anterior wall AMI.

Cooperative mediation by serotonin S2 and thromboxane A2/prostaglandin H2 receptor activation of cyclic flow variations in dogs with severe coronary artery stenoses.

We have reported previously that thromboxane A2/prostaglandin (PG)H2 and serotonin independently mediate the occurrence of cyclic flow variations (CFVs) in a canine preparation of severe coronary artery narrowing. This may be due to an effect of these substances on platelets and/or the vascular wall. We tested the hypothesis that there is a cooperative effect between thromboxane A2/PGH2 and serotonin receptor stimulation in the development of CFVs in this animal preparation. After placement of a hard plastic cylindrical constrictor around the left anterior descending coronary artery, CFVs develop and are characterized by repetitive cycles of declines in coronary blood flow and abrupt increases in flow. In a control group of dogs, CFV frequency (cycles/hour) and severity (lowest coronary blood flow just before its restoration) did not change significantly over a 3 hr interval. In a second group of dogs, CFVs were established after constrictor placement, abolished with the serotonin (5HT2) receptor antagonist ketanserin, and reestablished by the continuous infusion of serotonin into the left atrium. Serotonin-induced CFVs were then abolished with a thromboxane A2/PGH2 receptor antagonist, SQ29,548, or a thromboxane synthetase inhibitor, dazoxiben (UK37,248). The relative specificity of the respective antagonists, SQ29,548 and ketanserin, was determined in canine platelets and rat aortic vascular strips. No significant cross-reactivity between ketanserin and SQ29,548 was found. Thus, the data obtained in these studies demonstrate a cooperative interaction between thromboxane A2/PGH2 and serotonin S2 receptors that contributes to the development of CFVs in this experimental preparation.

Coronary artery bypass surgery in patients aged 80 years or older

Between August 1980 and January 1986, 23 patients aged 80 years or older underwent coronary artery bypass grafting (CABG) operations. These patients had a higher incidence of severe left main coronary artery narrowing (p <0.0001), 3-vessel coronary artery disease (p <0.05) and moderate to severe left ventricular dysfunction (p <0.05) than patients in the Coronary Artery Surgery Study registry older than 65 years. Of 14 patients undergoing elective simple CABG procedures, none died; of 19 elective cases overall, 2 patients died (11%). Three of 4 patients undergoing emergency procedures (75%) and 4 of 6 patients (67%) requiring intraaortic balloon counterpulsation died. Significant complications occurred in 9 of 18 survivors (50%). All operative survivors improved at least 1 New York Heart Association class, with a mean classification improvement of 3.7 to 1.6 (p <0.0001); 13 of 16 long-term survivors were in class I or II. Actuarial survival at 1 and 2 years is 94% and 82%, respectively. CABG can be performed effectively in octogenarian patients with increased but acceptable mortality and morbidity risks. Functional improvement and long-term survival are excellent.

Diabetes mellitus for 25 years or more. Analysis of cardiovascular findings in seven patients studied at necropsy

Observations are described in seven patients (four women and three men) aged 38 to 76 years who had had diabetes mellitus for 25 years or more. Five had been treated with insulin, and two had been treated with diet and oral hypoglycemic agents only. Four patients had had bilateral leg amputations, one angina pectoris, and two left-sided congestive heart failure. Two died suddenly, two died of acute myocardial infarction, two died of infection, and one died from trauma. Transmural left ventricular scars were present in five patients and transmural necrosis in three patients. All seven patients had two or more major epicardial coronary arteries narrowed more than 75 percent in cross-sectional area by atherosclerotic plaque. Of 353 segments, each 5 mm, from the four major epicardial coronary arteries from the seven patients (mean 50 per patient), 53 (15 percent) were narrowed up to 25 percent in cross-sectional area, 116 (33 percent) were narrowed 26 to 50 percent, 110 (31 percent) were narrowed 51 to 75 percent, 66 (19 percent) were narrowed 76 to 95 percent, and eight (2 percent) were narrowed 96 to 100 percent. What allowed such long survival in these seven patients is unclear. It is clear that all had severe coronary arterial narrowing by atherosclerosis.

Severe atherosclerotic coronary artery disease, healed myocardial infarction and chronic congestive heart failure: analysis of 81 patients studied at necropsy

Observations are described in 81 necropsy, patients (aged 29 to 91 years [mean 62]; 77 [95%]men) with severe congestive heart failure (CHF) more than 3 months in duration, left ventricular (LV) transmural scar and >75% cross-sectional area narrowing by atherosclerotic plaque of 1 or more of the 4 major epicardial coronary arteries. The duration of symptoms from initial onset of acute myocardial infarction (59 patients) or CHF (18 patients) or angina pectoris (2 patients) to death ranged from 0.5 to 18 years (mean 7.1) (2 unknown). Angina pectoris occurred at some time, however, in 31 patients (38%). Cause of death was CHF In 48 patients (59%), sudden (arrhythmia) in 16 (20%), acute myocardial infarction in 11(14% ), and emboli in 6 (7% ). The heart weight ranged from 410 to 800 g (mean 585). Left or right ventricular thrombi or both occurred in 37 patients (46%), only 4 (10%) of whom had systemic emboli; of the 44 patients without intracardiac thrombi, none had any form of emboli. The severity of coronary narrowing was variable. In 24 patients (30%) only 1 artery was narrowed >75% in cross-sectional area; in 22 patients (27% ), 2 arteries were so narrowed; in 32 patients (39%), 3 arteries; and in 3 patients (4%), 4 arteries. The size of the LV scar also varied. Of the 81 patients, 58 (72%) had large scars (Involving >40% of the LV wall); 10 (12%) had moderate-sized scars (6 to 40% of the LV wall); and 13 (16% ) had small scars (⪯5% of the LV wall). Size of the LV scar correlated with a history of habitual alcoholism: of the 16 habitual alcoholics, 6 (38%) had small and 8 (50%) had large LV scars; of the 65 non-alcoholics, 7 (11%) had small and 50 (77%) had large LV scars (p < 0.05). Chronic CHF In the 68 patients with either moderate or large-sized LV scars is readily attributed to the LV damage; In the 13 patients with small LV scars, however, chronic CHF more reasonably may be attributed to another factor, e.g., alcoholism, despite coronary artery narrowing similar in severity to that in the patients with large LV scars.

Subendocardial infarction in retrospect: pathologic, cardiographic, and ancillary features.

Fifty-three patients with subendocardial infarction (SEMI) were studied at autopsy; all were elderly and the group was equally divided by sex. About half had more than one SEMI; the recurrences or extensions often involved superjacent, but not infrequently adjacent, areas. Six showed fibrinous pericarditis. This larger study showed more widespread and severe coronary narrowing than an earlier report. Six patients had thrombi in the right coronary artery. Six showed electrocardiographic evidence of concomitant anteroseptal and inferior (Roesler-Dressler) infarction, and 12 had intraventricular block generally preceding higher-grade block or arrhythmias. At some time during their terminal hospitalization, 27 patients, or half, developed distinctive protracted RS-T depression or T wave inversion. Twenty-four of the SEMIs were diagnosed on accepted criteria as transmural infarct; that diagnosis was sustained in only four. Thus neither the presence of changes in RS-T segment or T wave nor the absence of QRS changes are mandatory for the diagnosis of SEMI; this invalidates the common assumption that the diagnosis is not justified unless these conditions are met.